MEDICARE: MAGGIE DEVILLE SLP-CCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	7105	LA

General Provider Information

NPI Number	:	1508404468
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAGGIE DEVILLE SLP-CCC

Provider Business Mailing Address
First Line	:	12072 GRIFFITH RD
Second Line	:
City	:	GONZALES
State	:	LA
Zip	:	70737-6478
Country	:	US
Telephone Number	:	225-715-9745
Fax Number	:

Provider Business Practice Location Address
First Line	:	12072 GRIFFITH RD
Second Line	:
City	:	GONZALES
State	:	LA
Zip	:	70737-6478
Country	:	US
Telephone Number	:	225-715-9745
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2019
Last Update Date	:	12/11/2019

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Directions to “ MAGGIE DEVILLE SLP-CCC” Practice Location

Language	Start Address	Practice Location

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